On Railway and Other Injuries of the Nervous System

John Eric Erichsen, the son of a wealthy merchant, was born in Copenhagen. His mother and grandmother were English, and Erichsen was sent to England for his education at the Mansion House School at Hammersmith. He studied medicine at the University College, London, where he was a pupil of Robert Liston. His training was completed by an extended visit to hospitals and clinics in Paris. He returned to work at the University College Hospital, becoming the Professor of Surgery in 1850. Although he wrote several important papers dealing with air embolism and the effects of the ligation of the coronary arteries, he was best known for his textbook, The Science and Art of Surgery: Being a Treatise on Surgical Injuries, Diseases, and Operations, which was first published in 1873. This was the most popular textbook of surgery of the last 1/2 of the nineteenth century. In addition to editions published in the United States, it was also translated into several foreign languages.

My object in these Lectures will be to direct your attention to certain injuries and diseases of the spine arising from accidents, often of a trivial character-from shocks to the body generally, rather than from blows upon the back itself-and to endeavour to trace the train of progres-sive symptoms and ill effects that often follow such injuries.
These concussions of the spine and of the spinal cord not unfrequently occur in the ordinary accidents of civil life, but from none more frequently or with greater severity than in those which are sustained by passengers who have been subjected to the violent shock of a railway collision; and it is to this particular class of injuries that I am especially desirous of directing your attention. For not only have they, in consequence of the extension of railway traffic, become of late years of very frequent occurrence, but, from the absence often of evidence of outward and direct physical injury, the obscurity of their early symp- toms, their very insidious character, the slowly progressive development of the secondary organic lesions, and functional disarrangements entailed by them, and the very uncertain nature of the ultimate issue of the case, they constitute a class of injuries that often tax the diagnostic skill of the surgeon to the very utmost. In his endeavours not only to unravel the complicated series of phenomena that they present, but also in the necessity that not unfrequently ensues of separating that which is real from those symptoms which are the consequences of the exaggerated importance that the patient attaches to his injuries, much practical skill and judgment are required.
The secondary effects of slight primary injuries to the nervous system do not appear, as yet, to have received that amount of concentrated attention on the part of surgeons that their frequency and their importance demands; and this is the more extraordinary, not only on account of the intrinsic interest attending their phenomena, but also from their having become of late years a most important branch of medico-legal investigation. There is no class of cases in which medical men are now so frequently called into the witness-box to give evidence in courts of law, as in the determination of the many intricate questions that often arise in actions for damages against railway companies for injuries alleged to have been sustained by passengers in collisions on their lines; and there is no class of cases in which more discrepancy of surgical opinion is elicited than in those now under consideration.
It is with the view and in the hope of clearing up some of the more obscure points connected with these injuries, that I bring this important subject before you; for I believe that, as these cases come to be more carefully studied, and consequently to be better understood, by surgeons, much of the obscurity that has hitherto surrounded them will be removed, and we shall less frequently see those painful contests of professional opinion which we have of late been so often constrained to witness in courts of law.
That discrepancy of opinion as to relations between apparent cause and alleged effect; as to the significance and value of particular symptoms, and as to the probable result in any given case, must always exist, there can be no doubt, more especially where the assigned cause of the evil appears to be trivial, where the secondary phenomena develop themselves so slowly and so insidiously that it is often difficult to establish a connecting link between them and the accident.
And for the existence of such discrepancy of opinion, and for the expression of it, if necessary, on oath-as a matter of opinion, merely-a very undue amount of blame has been cast on members of the medical profession.
In well-marked and clearly-defined cases of injury, where the physical lesion is distinct-as in a fracture-or the general symptoms unmistakable, as in the loss of sight or hearing, or in the sudden and immediate induction of paralysis-no discrepancy of opinion can or ever does exist; and I have no hesitation in saying that in at least nineteen-twentieths of all the railway or other accidents that are referred to surgeons of experience for arbitration or opinion, there is no serious difference as to the real nature of the injury sustained, or as to its probable result on the patient, either locally or constitutionally, immediately or remotely. But in a certain small percentage of cases, in which, as has already been said, the relation between alleged cause and apparent effect may not always be easy to establish, in which the symptoms come on slowly and gradually, in which they may possibly be referable to other constitutional states, quite irrespective of and pre-existing to the alleged injury, and in which the ultimate result is necessarily most doubtful, being dependent on many modifying circumstances; in such cases, I say, discrepancy of professional opinion may legitimately, and indeed must necessarily, exist. There is no fixed standard by which these points can be measured. Each practitioner will be guided in his estimate of the importance of the present symptoms, and of the probable future of the patient, by his own individual experience or preconceived views on these and similar cases. But, in these respects such cases differ in no way from many others of common and daily occurrence in medical and surgical practice. We daily witness the same discrepancies of opinion in the estimate formed by professional men of obscure cases of any kind. In cases of alleged insanity, in the true nature and probable cause of many complicated nervous affections, in certain insidious and obscure forms of cardiac, pulmonary, and abdominal disease; in such cases as these we constantly find that "quot homines tot sententice" still holds good. Even in the more exact science of chemistry, how often do we not see men of the greatest experience differ as to the value of any given test, as to the importance of any given quantity of a mineral-as of arsenic, mercury, or antimony, found in an internal organ-as organ-as an evidence of poisoning.
Far be it from me to do otherwise than to speak with the utmost respect of a learned and liberal profession, when I say that slight discrepancies of opinion arising between medical men are often magnified by the ingenuity of advocates, so as to be made to assume a very different aspect to that which they were intended to present, and are exaggerated into proportions which those who propounded them never meant them to acquire. Medical men deal habitually with the material rather than the ideal, with facts rather than with words, and are frequently, perhaps, at times somewhat inexact in the expressions they use. Mere verbal differences, mere diversities in modes of expressing the same fact, are thus sometimes twisted into the semblance of material discrepancies of statement and opinion.
How often have I not heard in courts of law attempts made to show that two surgeons of equal eminence did not agree in their opinions upon the case at issue, because one described a limb as being "paralytic," whilst the other perhaps said "there was a loss of nervous and muscular power in it"-when one said that the patient "dragged" a limb, the other that he "walked with a certain awkwardness of gait." The obvious professional moral to be deduced from this is, that it is impossible for you to be too precise in the wording of your expressions when giving evidence on an obscure and intricate question. However clear the fact may be to your own minds, if it be stated obscurely, or in terms that admit of a double interpretation, you may be sure that the subtle and practised skill of those astute masters of verbal fence who may be opposed to you, will not fail to take advantage of the opening you have inadvertently given them, to aim a fatal thrust at the value of your evidence. It is your province to give a distinct and clear description of the facts that you have observed, and an unbiased and truthful opinion as to the inferences you draw from them. It is their business to elicit the Truth, and to place the cause of their client in the best possible light, by questioning the accuracy of your facts and by sifting the validity of the opinions you have deduced from them.
I purpose illustrating these lectures by cases drawn from my own practice, and by a reference to a few of the more interesting published cases that bear upon the subject. In doing so, I shall confine myself to the detail of a few selected instances. It would be as useless as it would be tedious to multiply them to any great extent, as they all present very analogous trains of symptoms and phenomena. I will not confine my illustrations to cases drawn from railway accidents only, but will show you that precisely the same effects may result from other and more ordinary injuries of civil life. It must, however, be obvious to you all, that in no ordinary accident can the shock be so great as in those that occur on railways. The rapidity of the movement, the momentum of the person injured, the suddenness of its arrest, the helplessness of the sufferers, and the natural perturbation of mind that must disturb the bravest, are all circumstances that of a necessity greatly increase the severity of the resulting injury to the nervous system, and that justly cause these cases to be considered as somewhat exceptional from ordinary accidents. This has actually led some surgeons to designate that peculiar affection of the spine that is met with in these cases as the "railway spine." But yet, though the intense shock to the system that results from these accidents, naturally and necessarily gives to them a terrible interest and importance, do not for a moment suppose that these injuries are peculiar to and are solely occasioned by accidents that may occur on railways.
There never was a greater error. It is one of those singular mistakes that has arisen from men trusting too much to their own individual experience, and paying too little heed to the observations of their predecessors. It is an error begot in egotism and nurtured by indolence and selfcomplacency. It is easy for a man to say that such and such a thing cannot exist, because, "I, in my large experience at our hospital, never saw it," and not to trouble himself to learn, by the study of their works, that surgeons of equally large, or perhaps of far greater, experience in their generation, have seen and have described it.
Sir Astley Cooper, who certainly enjoyed a wider range of experience in surgical practice than has ever before or since fallen to the lot of any one man in this country, said that his experience, extensive as it had been, was only as a bucket of water out of the great ocean of surgical knowledge.
My object in the present lectures is to direct your attention to a class of cases in which the injury inflicted upon the back is either very slight in degree, or in which the blow, if more severe, has fallen upon some other part of the body than the spine, and in which, consequently, its influence upon the cord has been of a less direct and often of a less instantaneous character.
These cases are extremely interesting to the surgeon, for not only is the relation between the injury sustained and the symptoms developed less obvious than in the former case, but in consequence of the length of time that often intervenes between the occurrence of the accident and the production of the more serious symptoms, it becomes no easy matter to connect the two in the relation of cause and effect.
Symptoms indicative of concussion of the spine have of late years not unfrequently occurred, in consequence of injuries sustained in railway collisions, and have been very forcibly brought under the observation of surgeons in consequence of their having been the fertile sources of litigation; actions for damages for injuries alleged to have been sustained in railway collisions having become of such very frequent occurrence as now to constitute a very important part of medico-legal inquiry.
The symptoms arising from these accidents have been very variously interpreted by surgeons, some practitioners ignoring them entirely, believing that they exist only in the imagination of the patient, or, if admitting their existence, attributing them to other conditions of the nervous system than any that could arise from the alleged accident. And when their connection with, and dependence upon, an injury have been incontestably proved, no little discrepancy of opinion has arisen as to the ultimate result of the case, the permanence of the symptoms, and the curability or not of the patient. I shall illustrate these various points by selected cases, not only of persons who have been injured on railways, but in the ordinary accidents of civil life.
I wish particularly to direct your attention to the fact that there is in reality no difference whatever between the symptoms arising from a concussion of the spine received in a railway collision and those from a fall or ordinary accident-except perhaps in severity-and that it is consequently an error to look upon a certain class of symptoms as special to railway accidents. I cannot, indeed, too strongly impress upon you the fact that there is in reality nothing special in railway injuries, except in the severity of the accident by which they are occasioned. They are peculiar in their severity, not different in their nature from injuries received in the other accidents of civil life. There is no more real difference between that concussion of the spine which results from a railway collision and that which is the consequence of a fall from a horse or a scaffold, than there is between a compound and comminuted fracture of the leg occasioned by the grinding of a railway carriage over the limb and that resulting from the passage of the wheel of a street cab across it. In either case the injury arising from the railway accident will be essentially of the same nature as that which is otherwise occasioned, but it will probably be infinitely more severe and destructive in its effects, owing to the greater violence by which it has been occasioned. I intend to draw my illustrations, to some extent at least, from ordinary accidents, as in these the question of compensation in money for injury sustained is not mooted, and hence an element which is usually alleged to have a disquieting effect on the nervous system of the sufferer is eliminated from our consideration.
Case 5.-Mr. R., 35 years of age, a farmer and miller, of very active habits, accustomed to field sports, and much engaged in business, habitually in the enjoyment of good health, was in a railway collision that took place on Nov. 4, 1864. He received a blow upon his face which cut his upper lip on the left side, and was much and severely shaken. He did not lose consciousness, and was able shortly to proceed on his journey. On leaving the station to proceed to his own home, it was observed by a friend who drove him that he did not appear to recollect the road, with which he was familiar, having been in the daily habit of driving over it for years.
On reaching home, feeling bruised, shaken, and confused, he took to his bed, but did not feel sufficiently ill to seek medical advice until November 9, five days after the accident, when he sent to Mr. Yorke, of Staunton, who continued to attend him. But notwithstanding every attention from that gentleman, he progressively, but slowly got worse.
I saw Mr. R. for the first time on the 18th February, 1866, fifteen months after the occurrence of the accident, when I found him in the following state. His face was pallid, much lined, indicative of habitual suffering. He looked much older than his alleged age (36 years). He was sitting with his back to the light, and had the venetian blinds drawn down so as to shade the room, the light being peculiarly distressing to him. His skin was cool. Tongue slightly furred, appetite moderate, digestion impaired. Pulse 104 to 106, weak and compressible. I understand from Mr. Yorke that it rarely fell below this, and often rose above it. He has not lost flesh, but all his friends say that he is quite an altered man.
He states that since the accident his memory has been bad-that he cannot recollect numbers-does not know the ages of his children, for instance-he cannot add up an ordinary sum correctly-he will add up the same set of figures if transposed differently. Before the accident he was considered to be a peculiarly good judge of the weights of beasts-since its occurrence he has lost all power of forming an opinion on this point. He has been quite unable to transact any business since the injury. Is troubled with frightful dreams. Starts and wakes up in terror, not knowing where he is. Has become irritable, and can neither bear light nor noise. He frowns habitually, so as to exclude the light from his eyes. He complains of stars, sparks, flashes of light and coloured spectra flaming and flashing before the eyes. He cannot read for more than two or three minutes at a time, the letters becoming confused, and the effort being painful to bear. On examining the state of the eyes, I find that vision is good in the right eye, but that this organ is over sensitive to light. Vision is nearly lost in the left eye, so much so that he cannot read large print with it.
His hearing is over sensitive with the right ear, dull on the left side. He cannot bear noises of any kind, more particularly if sudden; they are peculiarly distressing to him. Even that of his children at play annoys him.
He complains of a numb sensation accompanied by tingling, burning sensations on the right side, in the right arm and leg, more particularly in the little and ring fingers, and along the course of the ulnar nerve. The rest of the right hand feels numb. He makes no complaint of the left arm or leg. These sensations are worst in the morning.
He cannot stand or walk without the support of a stick, or by resting his hand on a piece of furniture. He can do so in this way on the left leg, but if he attempts to do so on the right foot the limb immediately bends, and sinks as it were under him. His gait is very peculiar. He separates the feet so as to make a straddling movement, and brings one foot very slowly before the other. He advances, the right foot less than the left, and does not raise the sole as far from the ground. The foot seems to come down too quickly. He does not drag with the toes, but does not raise the heel sufficiently, and is apt to catch it in walking in inequalities on the ground. Flexion and extension are more perfectly and rapidly performed with the left than the right foot.
The attitude of his body in walking is very peculiar: the back is stiff, the head fixed, and he looks straight forward without turning it to the one side or the other.
He has great difficulty in going up or down stairs, cannot do so without holding on by the banisters. The difficulty is greatest in going down stairs, and if he attempts this without support he falls or rolls over to the right side.
There is no appreciable difference in the size of the two legs, but the right feels colder than the left. The patient complains of the coldness of both legs and feet.
The spine had lost its natural flexibility, so that the patient kept the body perfectly straight, fixed, and immovable. He could not bend the body in any direction without suffering severe pain. This was complained of equally whether the patient bent forwards, backwards, or sideways. It was most severe on any attempt being made to twist the spine. He sits in a rigid and upright attitude.
There was considerable pain at the occipito atloid articulation, as also at that between the axis and atlas. If an attempt was made to bend the head forcibly forwards, or to rotate it, the patient suffered so severely that it became necessary to desist. When directed to look round, the patient turned the whole body.
Owing to the rigidity of his spine he could not stoop so as to pick anything off the floor without going down on one knee.
On examining the spine by pressure and percussion, three tender spots were found; one in the upper cervical, the other in the middle dorsal, and the third in the lumbo-sacral region. There is pain both on superficial and on deep pressure at these spots. The pain is limited to the spine, and does not extend to the muscular structures on either side of it.
The power of retaining the urine is very materially diminished. He passes water four or five times in the night, and every second hour during the day. The urine is sub acid.
The generative power, though impaired, is not lost. A remarkable circumstance has been noticed in this case by Mr. R.'s wife and his friends. It is that since the accident he is unable to judge correctly of the distance of objects in a lateral direction, though he appears to be able to do so when looking straight forward. Thus, when driving in the middle of a straight road he always imagines that the carriage is in danger of running into the ditch or hedge on the near side.
The opinion I gave was, that the patient had sustained an injury of the spinal cord, and that the base of the brain was also, to some extent, though probably secondarily, involved. That chronic subacute meningitis of the spine and base of the cranium had taken place. That it was not probable that he would ever completely recover, and that it was even doubtful whether, as the disease had up to the present time been progressive, it might not continue to be so, and terminate in incurable disorganization of the nervous centres. The patient was seen by Sir Charles Hardings and Mr. Carden, who took a similarly unfavourable view of his present state and probable future.
An action was brought at the spring assizes at Worcester, in 1866, against the company on whose line the patient had been injured. No surgical evidence was called for the company, the statement made by the plaintiff's medical advisers being accepted. The question of damages resolved itself, to a great extent, into one of loss of income and expense incurred. The jury awarded £5775.